Healthcare Provider Details

I. General information

NPI: 1245225671
Provider Name (Legal Business Name): GENE E LANDIS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73D WINTHROP AVE PLAZA 114
LAWRENCE MA
01843-3716
US

IV. Provider business mailing address

73D WINTHROP AVE PLAZA 114
LAWRENCE MA
01843-3716
US

V. Phone/Fax

Practice location:
  • Phone: 978-686-3017
  • Fax: 978-685-4280
Mailing address:
  • Phone: 978-686-3017
  • Fax: 978-685-4280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number104248
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: